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General NPI Number Information
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NPI Number | 1003460551
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Entity Type | Organization
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Legal Business Name | AFFORDABLE DENTURES & IMPLANTS - GREEN BAY, S.C.
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Dates
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Enumeration Date | 08/01/2019
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Last Update Date | 08/01/2019
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Provider Practice Location Address
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Address Line | 1800-C W. MASON STREET
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City | GREEN BAY
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State | WI
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Zip | 54303
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Country | US
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Telephone | 920-499-7159
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Fax |
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Provider Business Mailing Address
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Address Line | 1800-C W. MASON STREET
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City | GREEN BAY
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State | WI
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Zip | 54303
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Country | US
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Telephone | 920-499-7159
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOHN PETTY
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Credential | DDS
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Telephone | 920-499-7159
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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